Program of all-inclusive care for the elderly (PACE)

Revised date
Purpose statement

The program of all-inclusive care for the elderly (PACE) provides long-term services and supports (LTSS), medical, mental health and chemical dependency treatment through a department-contracted managed care plan using a personalized plan of care for each enrollee.

WAC 182-513-1200 and WAC 182-513-1230 describes the eligibility for PACE.

WAC 182-513-1200 Long-term services and supports authorized under Washington Apple Health programs

WAC 182-513-1200 Long-term services and supports authorized under Washington Apple Health programs

Effective February 20, 2017

  1. Long-term services and supports (LTSS) programs available to people eligible for noninstitutional Washington apple health coverage who meet the functional requirements.
    1. Noninstitutional apple health coverage in an alternate living facility (ALF) under WAC 182-513-1205.
    2. Community first choice (CFC) under WAC 182-513-1210.
    3. Medicaid personal care (MPC) under WAC 182-513-1225.
    4. For people who do not meet institutional status under WAC 182-513-1320, skilled nursing or rehabilitation is available under the CN, medically needy (MN) or alternative benefits plan (ABP) scope of care if enrolled into a managed care plan.
  2. Non-HCB waiver LTSS programs that use institutional rules under WAC 182-513-1315 and 182-513-1380 or HCB waiver rules under chapter 182-515 WAC, depending on the person's living arrangement:
    1. Program of all-inclusive care for the elderly (PACE) under WAC 182-513-1230.
    2. Roads to community living (RCL) under WAC 182-513-1235.
    3. Hospice under WAC 182-513-1240.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

Eligibility for PACE is based on institutional or home and community-based (HCB) waiver rules; the rules depends on the setting a person resides. If in a medical facility, institutional rules are used for financial eligibility. If in the home or community, waiver rules are used for financial eligibility.

WAC 182-513-1230 Program of all-inclusive care for the elderly (PACE)

WAC 182-513-1230 Program of all-inclusive care for the elderly (PACE).

Effective February 20, 2017

  1. The program of all-inclusive care for the elderly (PACE) provides long-term services and supports (LTSS), medical, mental health, and chemical dependency treatment through a department-contracted managed care plan using a personalized plan of care for each enrollee.
  2. Program rules governing functional eligibility for PACE are listed under WAC 388-106-0700, 388-106-0705, 388-106-0710, and 388-106-0715.
  3. A person is financially eligible for PACE if the person:
    1. Is age:
      1. Fifty-five or older and disabled under WAC 182-512-0050; or
      2. Sixty-five or older;
    2. Meets nursing facility level of care under WAC 388-106-0355;
    3. Lives in a designated PACE service area;
    4. Meets financial eligibility requirements under this section; and
    5. Agrees to receive services exclusively through the PACE provider and the PACE provider's network of contracted providers.
  4. Although PACE is not a home and community based (HCB) waiver program, financial eligibility is determined using the HCB waiver rules under WAC 182-515-1505 when a person is living at home or in an alternate living facility (ALF), with the following exceptions:
    1. PACE enrollees are not subject to the transfer of asset rules under WAC 182-513-1363; and
    2. PACE enrollees may reside in a medical institution thirty days or longer and still remain eligible for PACE services. The eligibility rules for institutional coverage are under WAC 182-513-1315 and 182-513-1380.
  5. A person may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the room and board and participation.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

PACE is a voluntary program that provides long-term care and acute medical services to older and disabled clients. The client can be enrolled in PACE in their own home, a residential setting, or in a medical institution. Enrollment is effective the first day of the month and disenrollment is effective the last day of the month. Clients are eligible for PACE services on the first of the month following the date the client is financially and functionally eligible.

There are a few exceptions to regular institutional rules. A person must be 55 years of age or older for PACE and there are no transfer of asset penalties. Modified Adjusted Gross Income (MAGI) clients are also eligible to be enrolled in PACE.

Clients receiving PACE in a medical institution are required to pay towards their PACE services under institutional post-eligibility rules (WAC 182-513-1380). A client in the community pays for their PACE services using the rules for Home and Community Services (HCS) HCB waiver post-eligibility rules (WAC 182-515-1509). If the client receives PACE under a MAGI Medicaid program, they do not pay participation.

PACE is "all inclusive;" a person should not have out-of-pocket medical expenses (e.g., health insurance, copayments, etc.). When a PACE enrollee reports medical expenses, they cannot be allowed as deductions. The client is not required to pay the expense, the expenses are covered by PACE.

Worker Responsibilities

ACES requires a PACE Provider ID and the Provider ID can be located in ACES Provider Search. The financial worker will enter the Provider ID along with the HCBS indicator (A) for PACE. The indicator will drive eligibility for L31 and L32 programs. Since the PACE Provider has its ID entered, the PACE provider receives all LTC-related letters.

Financial will be notified by the end of the month prior to PACE enrollment date. ACES does not allow future start dates, so financial will process the program change or approval on the first business day of the month that PACE services are authorized.

Note: The L31 & L32 coverage groups are used for both hospice as a program and PACE. This is because both hospice as a program and PACE both use the same HCB waiver rules for eligibility. ACES determines which program (hospice or PACE) a client is on based on the service indicator and facility coded on the ACES institutional services screen. A PACE recipient cannot receive hospice as a service because they receive all care through the PACE provider.

HCS Financial staff are not responsible for ongoing maintenance of a MAGI PACE client unless client is no longer eligible for their MAGI Medicaid program. HCS Financial will redetermine the appropriate Medicaid program for ongoing coverage if the client is financially eligible.

When a PACE client disenrolls from PACE, the HCS Financial staff will receive a Financial / Social Services Communication form (DSHS 14-443) indicating the client’s disenrollment. Disenrollment from PACE is effective the last day of the month. The client should be redetermined for other Medicaid programs and the financial staff should coordinate with social services to determine if other HCS services will be authorized in the ongoing months.

Related Links

Social Service WACs:

388-106-0700 What services may I receive under PACE?

388-106-0705 Am I eligible for PACE services?

388-106-0710 How do I pay for PACE services?

388-106-0715 How do I end my enrollment in the PACE program?

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Non-Grant Medical Assistance (NGMA) hearings

Revised date

Clarifying information

The Office of Administrative Hearings schedules the following hearing types as HCA Hearings and sends a notice of the hearing to the DSHS Administrative Hearing Coordinator (AHC):

  • Non-Grant Medical Assistance decisions made by Division of Disability Determination Services (DDDS).
  • Medical Assistance decisions made by the Health Care Authority regarding:
    • Medical equipment and services, or
    • Managed care eligibility or services, or
    • Restricted use of medical care, or
    • Coordination of Benefits (TPL) issues.

Representation may be from the department, agency, or office that made the decision (e.g. issue related to denial of a medical service or choice of a managed care plan).

In most situations, the AHC acts as the agency representative and the other office or agency provides witnesses to testify regarding the Department or agency decision that is being contested.

AHC responsibilities

There are several offices within the (HCA) that make decisions which are subject to administrative hearings. It is important to contact the appropriate office as soon as a notice of hearing is received to coordinate representation.

  1. Medical assistance hearings:
    1. For hearings involving medical services, equipment, transportation, managed care enrollment, and Patient Review and Coordination (PRC) program contact the HCA's Office of Hearings and Appeals at: MS 445531, 360-725-1254 or 800-351-6827.
      1. The HCA staff may act as the agency's representative for these cases, coordinate testimony of medical consultants, help obtain additional medical information, and arrange medical examinations, if necessary.
      2. The HCA Appeals Administrator will coordinate review and implementation of hearing decisions as required by HCA.
      3. The DSHS AHC acts as liaison between HCA staff and the Appellant and their representative if required. For example, if the Appellant requests an in-person hearing and it is scheduled at the local CSO, the DSHS AHC may assist the ALJ and the Appellant during the hearing because HCA staff participates in the hearing telephonically from Olympia, WA.
  2. For insurance issues, contact HCA's Revenue, Recovery and Premium Payment Section or HCA's Coordination of Benefits Section, as appropriate:
    1. COB Health Units: 800-562-3022 ext # 16134
    2. COB Casualty Unit: 800-562-3022 ext # 15462
    3. RRPS Premium Payment: 800-562-3022 ext # 15473
  3. For eligibility and policy issues, when clarification is required, contact the eligibility representative in the Office of Medicaid Eligibility & Policy (OMEP), MS 45534.
  4. For hearings involving CHIP (N13), After Pregnancy Coverage (N04/N24/N07/N27), BCCTP (S30) or other cases assigned to CSO 76 contact Ariane Takano 360-725-1795 MS 45531 or contact 800-351-6827.
  5. Non-grant medical assistance (NGMA) hearings: The AHC acts as the agency representative, and a Division of Disability Determination Services (DDDS) employee provides testimony to support the decision. Individuals have up to 90 days to request a hearing on a NGMA decision. As soon as the hearing request is received:
    1. Initiate reconsideration of the original decision by completing in hard copy a DSHS 14-144, Transmittal Summary, and check the box for Administrative Hearing Review. The reconsideration is a required step in the DDDS process prior to hearing. Request continuances as appropriate to allow sufficient time for the reconsideration.
    2. Forward the DSHS 14-144 and the DDDS original decision packet in hard copy to the appropriate DDDS office. Attach any new medical documentation and release of information authorizations, if appropriate. (Do not use the automated Barcode referral process for administrative hearing reviews.)
    3. Notify DDDS of the scheduled date and time of the hearing.
    4. Coordinate requested continuances from either the appellant or DDDS with the local OAH office. Continuances are often necessary in these cases to obtain additional medical information. It is important that the AHC keep all parties informed of the status of the case prior to the hearing.
    5. Notify the appellant if the original DDDS decision is reversed in the DDDS review process.
    6. If the original denial is affirmed in the DDDS review process, consult with the DDDS hearing supervisor who will assign someone to testify in support of the denial.

Note: A hearing request is not always needed for the Dept. to review a NGMA decision. Individuals may ask for a review within 30 days of the initial denial if medical evidence exists that was not used to make the original decision. Please follow the above steps and note on the referral that it is a reconsideration of denial.

DDDS hearings contact :
Michael Magill
Hearings manager
360-664-7394
MS 45550

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Change of circumstance

Revised date
Purpose statement

A person who is eligible for Medically Needy (MN) coverage with a spenddown liability is required to report changes in their circumstances following rules in WAC 182-504-0105. Whether the person has already met their spenddown liability or is still in pending status, we are required to consider the effect of the change on the individual's eligibility.

Worker Responsibilities

The following are some common examples of changes in circumstance and some guidance on the action needed by the worker.

The only eligible individual dies or becomes ineligible before the end of the base period

In this situation you will need to shorten the base period and recalculate the spenddown amount, whether the spenddown has been met or not.

Example: Dennis, an SSI-related individual, elected a 6-month base period and had a total spenddown liability of $738 ($123 per month). Sadly, Dennis passes away in month 4 of the base period. The worker should close the case. If Dennis was still in pending status and had not met spenddown, recalculate the spenddown based on a 4-month base period and send an amended letter showing the new amount to be $492. Note: There may be outstanding medical bills that can be applied to the spenddown even after Dennis' death.

The head of household/primary applicant passes away

When the HOH of a MAGI passes away, go to Healthplanfinder to report a change and remove the Primary Applicant (PA). This will close the deceased’s MAU as of the date of death.

If there are other active individuals receiving WAH under the deceased PA, those AUs will also close, but with advance and adequate notice.

When there is a surviving spouse and other dependents who are receiving WAH and there is enough information to redetermine eligibility, start a new application with the surviving spouse as the HOH and include the other dependents. Submit the application. Send them a general correspondence letter with the following text:

“Please accept our condolences for your loss. Based on the information we had on your household’s previous application, we have opened coverage with you as the head of household on a new application. If any of the information has changed or is incorrect, please create or log in to your Healthplanfinder account at www.wahealthplanfinder.org to correct the information. You may also call the Health Benefit Exchange call center at 1-855-923-4633 to report the change and update your application.”

If there is not enough information to redetermine eligibility, start an application, submit it, and request the needed information from the individual.

If there is no surviving spouse or the surviving spouse was not receiving WAH, those closed from MAGI will automatically receive a letter telling them to reapply.

The household reports an increase in income

If the individual reports an increase in income, we need to recalculate the spenddown amount for the remaining months in the base period.

If the individual has not met spenddown and is still in pending status, the worker needs to send a new letter to the individual indicating that their spenddown liability has increased.

If the individual has already met spenddown and the MN coverage is active, the worker needs to:

  • Terminate the MN coverage (with advance and adequate notice),
  • Recalculate the new spenddown liability for the remaining months in the base period, and
  • Send an amended spenddown letter, showing the additional amount of spenddown liability the household needs to incur.

When calculating the additional spenddown liability amount, the individual must be given a credit for the remaining months in the base period. The example below shows how to calculate the amount of the credit. Enter the credit amount as a paid expense type 'MU' in ACES and document that this is a workaround to give the individual the benefit of the credit. When the individual reapplies for MN coverage, the credit will be applied to the individual's new spenddown.

Example: Norma receives social security disability of $720 per month. Her spenddown liability is $156 ($26 per month) based on a 6-month base period from February through July.

She met her spenddown on March 10 and is active on MN medical. On May 5, she reports that she started receiving a small pension in the amount of $115 per month. Terminate medical coverage effective the end of May.

Recalculate the spenddown liability for the months of June and July. Since Norma had already met her spenddown for a 6-month period, and she has only received coverage for a 4-month period, we need to allow her a credit towards the new increased liability based on the number of months left until the end of the original base period. In this example, her spenddown amount was $26 per month so she receives a 'credit' of $104. ($26 x 4 months). Code the $104 as a paid expense type 'MU' in ACES online, and the credit will be applied to the individual's next base period.

The household reports a decrease in income

If the individual reports a decrease in income that brings their income below the CN income standard:

  • Close the medically needy assistance unit,
  • Screen the individual for the categorically needy (CN) program,
  • Recalculate the spenddown liability for the months prior to the approval for CN medical by shortening the base period, and
  • Send an amended spenddown letter to reflect the new liability amount for this prior period.

Example: Josie, a pregnant woman has income over 193% FPL at the time of her application for pregnancy medical. Her baby is due in July. In April, she reports and verifies she is no longer working and her income is now below the CN standard. The worker would approve Josie for CN medical (Apple Health for Pregnant Women) effective April 1 (the first of the month in which she reported her change and was found CN eligible). She is now continuously eligible for CN coverage through the birth and the 2 months post partum period.

The worker would also recalculate the spenddown amount for the prior months and send an amended letter to advise her of the lower amount. If she incurred medical expenses through March that were more than the recalculated spenddown amount, she would qualify for MN coverage and the agency would cover her medical expenses for the time period after she met her recalculated spenddown and before she became eligible for CN coverage.

The household reports a change in household composition

When the household reports a change in household composition (someone moves into or out of the home), the worker needs to recalculate the spenddown for the balance of the base period and giving 10 days advance and adequate notice if this is an adverse action.

Example: Someone moves out of the household

Katie, an SSI-related individual, applies for medical coverage in December. She is married and has a 17 year old daughter Lucy. Her spenddown liability is $300 for a 6-month base period.

In February, Lucy moves out of the home. With Lucy no longer living in the home, Katie's spenddown amount will increase because she loses the child allowance.

If Katie has not yet met spenddown, the worker should recalculate the spenddown amount for March, April and May without the child allowance and send an amended spenddown letter for the new total liability amount.

If Katie has already met spenddown, the worker should terminate MN coverage (giving advance and adequate notice of the adverse action) and generate a new letter showing the increase in additional spenddown liability.

Example: Someone moves into the household, causing household to qualify for CN coverage

Ken is 68 years old and lives alone. He has monthly income of $857 Social Security disability and has a spenddown of $978 with a base period from June through November. In July, he reports that his new wife Valerie moved into his home. Valerie has no income and has a current disability determination. She is applying for medical coverage for herself also.

Recalculate medical eligibility for her and Ken. Based upon their reported income, you determine this household is now CN eligible.

If Ken has already met spenddown, close his MN coverage and screen in a CN medical program for both, effective the first of the month in which he reported the change and in which Valerie applied for medical coverage for herself.

If Ken had not already met spenddown, authorize the CN coverage effective the first of the month in which he reported the change. Recalculate the spenddown liability for the months prior to the CN approval and generate an amended MN spenddown letter showing the reduced liability amount.

Example: Same as previous example, except Valerie does not apply for coverage and Ken does not qualify for CN coverage

The facts are the same as the example above, except that Valerie is not applying for medical coverage for herself or is not SSI-related. The worker would still need to redetermine the effect of the change on Ken's medical coverage. Since Valerie is a nonapplying spouse, the worker would reduce Ken's countable income by allocating income to her.

If Ken has not already met spenddown, recalculate eligibility for the months of July through November. With the spousal allocation, he would be eligible for MN without spenddown. The worker would:

  • Certify S95 coverage for Ken through the balance of the base period,
  • Recalculate the spenddown liability for June by shortening the base period to the month of June only, and
  • Send an amended spenddown liability for this month.

Ken will need to meet the new spenddown amount before June coverage could be approved.

Nonapplying spouse applies for medical coverage after applying spouse receives MN coverage

In many cases involving a married couple, individuals have to choose who will receive health care coverage because of the effects of income deeming. Couples may choose the same person for each base period or may alternate who gets coverage. However; there are some situations when MN coverage has already been certified for one spouse and the other spouse has a medical emergency where they also need coverage during the same base period. The following example explains the steps and calculations needed to determine eligibility for the new applying spouse.

Example: Jim and Carla are a married SSI-related couple. They have a 6-month base period from January through June. They both have income and the spenddown liability when both of them apply is too high for them to meet. However, when only one applies for coverage, their spenddown liability is reduced to $100 per month ($600 for six months). They opt to apply for MN coverage for Jim since he has a chronic ongoing health condition and he has no other coverage.

They present medical expenses to the agency in January, and they meet his spenddown liability of $600 on January 10.

On March 18, Jim calls his case worker and tells him that Carla was admitted to the hospital on March 3 and they need to apply for medical for her also. She was in the hospital for 4 days, and they now have a bill for $45,000 which they cannot pay.

The worker would do the following:

  • Terminate MN coverage for Jim effective March 31.
  • Screen in a new S02 AU with both Jim and Carla as applicants with a request date of March 1.
  • Shorten the base period to match the original S99 certification through the end of June.
  • Recalculate the spenddown liability for the period March through June (4 months) and send them a new letter showing the increased spenddown amount which includes both Jim and Carla's income.
  • Since Jim has already paid for his share of the 4 full months remaining in his base period, credit them $400 towards the new higher spenddown liability (4 months x the original $100 per month liability).
  • Code the $400 as a paid 'MU' expense in ACES so that it is credited towards the new spenddown amount.
  • Use the $45,000 hospital bill incurred on March 3 to meet the spenddown for both.

They will be responsible for the spenddown amount, but the agency will be able to pay on the balance of the bill for them.

For more information on income deeming and allocation, see SSI-Related - Income - Allocation and Deeming.

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Participation in a medical institution

Revised date
Purpose statement

Describes the post-eligibility treatment of income (PETI) process for individuals residing in a medical institution, who meet institutional status. The PETI process determines how much the individual must pay toward the cost of their institutional care. This amount is called participation or client responsibility toward the cost of care.

WAC 182-513-1380 Determining a client's financial participation in the cost of care for long-term care in a medical institution.

WAC 182-513-1380 Determining a client's financial participation in the cost of care for long-term care in a medical institution

Effective March 1, 2025

This rule describes how the agency or the agency's designee allocates income and excess resources when determining participation in the cost of care in a medical institution.

  1. The agency or the agency's designee defines which income and resources must be used in this process under WAC 182-513-1315.
  2. The agency or the agency's designee allocates nonexcluded income in the following order, and the combined total of (a), (b), (c), and (d) of this subsection cannot exceed the effective one-person medically needy income level (MNIL):
    1. A personal needs allowance (PNA) under WAC 182-513-1105.
    2. Mandatory federal, state, or local income taxes owed by the client.
    3. Wages for a client who:
      1. Is related to the supplemental security income (SSI) program under WAC 182-512-0050(1); and
      2. Receives the wages as part of an agency-approved or department-approved training or rehabilitative program designed to prepare the client for a less restrictive placement. When determining this deduction, employment expenses are not deducted.
    4. Guardianship fees, conservatorship fees, and administrative costs, including any attorney fees paid by the guardian or conservator, as allowed under chapter 388-79A WAC.
  3. The agency or the agency's designee allocates nonexcluded income after deducting amounts under subsection (2) of this section in the following order:
    1. Current or back child support garnished or withheld from income according to a child support order in the month of the garnishment if it is:
      1. For the current month;
      2. For the time period covered by the PNA; and
      3. Not counted as the dependent member's income when determining the dependent allocation amount under WAC 182-513-1385.
    2. A monthly maintenance needs allowance for the community spouse as determined using the calculation under WAC 182-513-1385. If the community spouse is also receiving long-term care services, the allocation is limited to an amount that brings the community spouse's income up to the PNA.
    3. A dependent allowance for each dependent of the institutionalized client or the client's spouse, as determined using the calculation under WAC 182-513-1385.
    4. Medical expenses incurred by the institutionalized individual and not used to reduce excess resources. Allowable medical expenses and reducing excess resources are described in WAC 182-513-1350.
    5. Maintenance of the home of a single institutionalized client or institutionalized couple:
      1. Up to 100 percent of the one-person federal poverty level per month;
      2. Limited to a six-month period;
      3. When a physician has certified that the client or couple is likely to return to the home within the six-month period; and
      4. When social services staff documents the need for the income deduction.
  4. A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the participation.
  5. A client is responsible to pay only up to the state rate for the cost of care. If long-term care insurance pays a portion of the state rate cost of care, a client pays only the difference up to the state rate cost of care.
  6. When a client lives in multiple living arrangements in a month, the agency allows the highest PNA available based on all the living arrangements and services the client has in a month.
  7. Standards under this section for long-term care are found at www.hca.wa.gov/health-care-services-supports/program-standard-income-and-resources.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

Income that remains after allowable deductions is the amount the client must pay toward the cost of care in the medical institution. The order and description of deductions follows WAC 182-513-1380. The combination of 1 - 4 can't exceed the medically needy income level (MNIL).

  1. Personal Needs Allowance (PNA)
  2. Mandatory taxes
  3. Wage deduction from department approved employment
  4. Guardianship fees and related attorney costs
  5. Court ordered child support
  6. Spousal maintenance allowance
  7. Dependent maintenance allowance
  8. Allowable medical expenses
  9. Home Maintenance Allowance (HMA)

Note: The 65 and 1/2 deduction is not allowed for earnings in a medical institution; however, a wage deduction is allowed, dollar for dollar, up to the MNIL after allowing the PNA and mandatory tax deduction. Approved wages are coded as RH ACES on the income screen. 

SSI Income:

When an individual enters a medical institution, the Social Security Administration (SSA) reduces the SSI cash payment to $30 per month. The full SSI benefit is continued, if SSA determines the individual's stay in the institution is not likely to exceed three months and the individual has expenses for maintaining a home. When SSA makes this determination, the full SSI benefit/State supplementary payment (SSP) is continued and is excluded in the post-eligibility process. 

Personal Needs Allowance (PNA):

Client's are allowed the highest PNA in a given month based on living arrangement, authorized service and marital status. If a client resides at home at least one moment in the month and admits into a nursing facility (NF) we would allow the in home PNA. 

Dependent and Family Allocation Calculation:

Family and dependent allocation

Home Maintenance Allowance (HMA):

The HMA is income that the client can keep to maintain their residence during their NF stay. The HMA is approved by the social worker/case manager. 

HMA can be approved for up to 6 months when it is determined the client is likely to return home within 6 months.

The monthly HMA amount is the current Federal Poverty Level (FPL).

There is no limit to HMA for multiple admissions and discharges to a NF. It is not allowed for more than 6 consecutive months.

Hospice:

Hospice index

Participation in the cost of care for hospice services received in a medical facility is determined according to WAC 182-513-1380. The client pays their participation amount to the hospice agency.

Changes in income and deductions using Method 1 and 2 for institutional cases.

For further information see LTC change of circumstance.

Worker Responsibilities

  1. To reduce excess resources, deduct amounts for medical expenses for which the client is liable. WAC 182-513-1350. See Allowable medical expenses.
  2. To reduce participation, deduct medical expenses not already used to reduce excess resources as described in WAC 182-513-1350. See Allowable medical expenses.
  3. Allocate the income of a client to a former spouse when the Court has ordered a spousal maintenance amount to be paid. These orders can be called Qualified Domestics Relations Order (QDRO) or alimony.
  4. Allocate the income of the client with a spouse or dependent. See Family and dependent allocation.
  5. Treat hospice revocation or discharge like any other change from one nursing facility to another. See Hospice.
  6. Clients receiving the $90 from Veteran's Administration are allowed to keep the $90 plus their PNA indicated under all other PNA Med Inst of the Washington Apple Health Income and Resource standard chart.  The $90 is to be coded as VA Non-Countable as unearned income.
  7. Approved wages are coded as Rehabilitation Income in ACES as earned income.
  8. The social worker/case manager notifies the Public Benefit Specialist (PBS) of the start date of the HMA when it has been approved. The PBS indicates the FPL as the HMA amount and codes the starting month in ACES.
  9. When a client changes providers or facilities during the month, code the discharge and admit dates. ACES will recalculate the participation between the 2 medical institutions.
  10. When changes in the participation amount are made and confirmed within ACES, the system automatically generates a notice to the client/ representative. Since some notices do not contain enough information, add sufficient freeform text to explain what changes are being made and the reason for them.
  11. Advance notice is not required to change a client's participation in the cost of care, since no reduction, suspension, or termination of services will result. A change in the participation amount is not considered an adverse action.

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Hospice special circumstances

Revised date
Purpose statement

Some cases require processing alternatives or fall outside of these instructions. 

  • If a single client elects hospice and receives noninstitutional Medicaid in an Alternative Living Facility (ALF), maintain eligibility under the G03/G95 series as these clients are paying their income toward the cost of care on this program. The hospice service can be added to the case.
  • Active MN Medicaid clients who have met spenddown and are placed in a nursing home would be allowed the following deductions to determine the amount of the client’s participation in the cost of care:
    • Allow the MNIL if the client is at home the first day of the month he or she is admitted to the facility, or the appropriate personal needs allowance (PNA) based on the client’s living arrangements if not at home on the first day of the month. Client’s monthly spenddown liability that has been met for each month through the certification period
    • Note: The spenddown liability deduction is coded on the institutional screen in ACES with notation in remarks. The determination of the MNIL/PNA is based on the information coded on the INST screen and DEM1 screen in ACES.
    • The $20.00 disregard used as a deduction for MN noninstitutional spenddown is counted towards the client’s monthly nursing home participation in the post eligibility process.

Example: Single client on Medicaid MN program with base period 1/2017-3/2017. Spenddown was met in February and case was certified effective 2/1/2017. Client has monthly income of $825 per month. He enters the nursing home from home on 3/5/2017.

His MN spenddown was computed as follows:

  • $825.00 monthly income
  • -$20.00
  • -735.00 MNIL
  • $70.00 per month available for spenddown use as a deduction

Nursing Home Participation for 3/2017 is computed as follows:

  • $825.00 monthly income
  • -$735.00 MNIL (at home 3/1/2017)
  • -$70.00 spenddown liability
  • $20.00 participation to the nursing facility.

The spenddown base period ended in March. This deduction can only be used through the last month of the original MN base period.

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Medical Care Services (MCS) program

Revised date
Purpose statement

The Medical Care Services (MCS) Program provides health care coverage to lawfully present recipients of Aged, Blind, or Disabled (ABD) cash assistance and the Housing and Essential Needs (HEN) Referral program who are unable to access other Washington Apple Health (Medicaid) programs due to their citizenship / immigration status.

Beginning February 1, 2022, MCS provides health care coverage to adult recipients of the State Family Assistance (SFA) for Survivors of Certain Crimes cash program who are unable to access other health care coverage due to their citizenship/immigration status.

Beginning July 1, 2022, MCS provides health care coverage to noncitizen Survivors of Certain Crimes who are recipients of ABD cash assistance or HEN referral programs.

WAC 182-508-0005 Washington apple health medical care services - eligibility and scope of coverage.

WAC 182-508-0005 Washington apple health medical care services - eligibility and scope of coverage.

Effective February 12, 2023

  1. A person is eligible for state-funded Washington apple health medical care services (MCS) coverage to the extent of available funds if the person is:
    1. Determined by the department of social and health services to be eligible for benefits under:
      1. The aged, blind, or disabled program as described in WAC 388-400-0060;
      2. The housing and essential needs referral program as described in WAC 388-400-0070; or
      3. The survivors of certain crimes (SCC) program, as described in WAC 388-424-0035, which includes victims of human trafficking as described in RCW 74.04.005;
    2. Not eligible for another federally funded categorically needy (CN) (as defined in WAC 182-500-0020) or alternative benefits plan (ABP) (as defined in WAC 182-500-0010) Washington apple health program and
    3. Not residing in a public institution as defined in WAC 182-500-0050.
  2. If an enrollment cap exists under WAC 182-508-0150, a waiting list of people may be established.
  3. A person's period of eligibility for MCS is the same as the person's period of eligibility for:
    1. The aged, blind, or disabled program as described in WAC 388-449-0150;
    2. The person's incapacity authorization period for the housing and essential needs referral program as described in WAC 388-447-0110;
    3. The person's period of eligibility for the SCC program as described in WAC 388-424-0035.
  4. The MCS program covers only the medically necessary services defined in WAC 182-501-0060.
  5. The MCS program does not cover medical services received outside the state of Washington unless the medical services are provided in a border city listed in WAC 182-501-0175.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying information

Individuals cannot apply for Medical Care Services (MCS); they access MCS by submitting an application for cash assistance online through Washington Connection, in person at their local DSHS Community Services Office, or over the phone at 877-501-2233.

In order to receive Medical Care Services (MCS), an individual must meet eligibility, income and resource requirements for either ABD cash assistance, Housing and Essential Needs (HEN) Referral or SFA for Survivors of Certain Crimes programs.

Survivors of Certain Crimes as described in WAC 388-424-0001(4) who are ineligible for State Family Assistance (SFA) for Survivors of Certain Crimes as described in WAC 388-400-0010, are potentially eligible for ABD cash as described in WAC 388-400-0060 and Housing and Essential Needs (HEN) Referral as described in WAC 388-400-0070. 

MCS eligibility begins when ABD cash eligibility begins; HEN Referral eligibility begins; or SFA for Survivors of Certain Crimes cash program eligibility begins.
MCS eligibility ends when ABD cash eligibility ends; or HEN Referral eligibility ends; or SFA for Survivors of Certain Crimes cash program eligibility ends.

Cash assistance requirements

In order to receive Medical Care Services (MCS) an individual must meet:

  1. ABD cash assistance eligibility requirements as described in WAC 388-400-0060; or
  2. HEN Referral requirements eligibility requirements as described in WAC 388-400-0070; or
  3. SFA for Survivors of Certain Crimes cash program eligibility requirements as described in WAC 388-400-0010. 

Income and resource requirements outlined in Chapter 388-450 WAC and the citizenship and immigration requirements outlined in WAC 388-424-0015; and for SFA for survivors of Certain Crimes as described in WAC 388-424-0001(4)(5).

ABD cash disability requirements outlined in WAC 388-449-0001 or HEN Referral incapacity requirements outlined in WAC 388-447-0001; Or for SFA for Survivors of Certain Crimes Workfirst mandatory participant requirements described in WAC 388-310-0400.

The monthly income limits for:

  • ABD cash and HEN Referrals are described in WAC 388-478-0090.
  • SFA for Survivors of Certain Crimes is described in WAC 388-450-0162.

The ABD cash program provides SSI Facilitation services and a maximum cash grant of $450 for a one person assistance unit, or $570 for a two person assistance unit, as described in WAC 388-478-0033.

The HEN Referral program does not provide a cash grant. HEN Referral recipients are eligible for essential needs items (e.g. hygiene and cleaning supplies) and potential housing assistance from the Department of Commerce through its network of local providers.

ABD cash and HEN Referral recipients are subject to both financial eligibility and disability/incapacity reviews. Financial eligibility reviews are conducted every 6 to 12 months as required by WAC 388-434-0005. ABD cash disability reviews are conducted at least every 24 months as required by WAC 388-449-0150. A HEN Referral incapacity review is conducted at least every 12 months as required by WAC 388-447-0110.

SFA for Survivors of Certain Crimes recipients are subject to financial eligibility reviews every 6 to 12 months as required by WAC 388-434-0005 and WAC 388-418-0011.

There is a potential enrollment cap for MCS outlined in WAC 182-508-0150. Since the enrollment cap was put into law, the agency has not implemented any limits or disenrollment actions because there has been adequate funding to serve the enrolled population.

Worker responsibilities

Worker responsibilities are carried out by CSD staff

  1. When an individual is approved for ABD cash assistance, HEN Referral, or SFA for Survivors of Certain Crimes, review the case to determine if they are Federally Qualified to receive Medicaid.
  2. If the individual is not Federally Qualified to receive Medicaid, screen in an A-track Assistance Unit (AU) for adult recipients and approve MCS for the same certification period as ABD cash assistance, HEN Referral, or SFA for Survivors of Certain Crimes.
  3. At the time of Mid-Certification Review, Eligibility Review, or Disability / Incapacity Review, extend MCS eligibility if the individual remains eligible for ABD cash assistance, HEN Referral, or SFA for Survivors of Certain Crimes.
  4. Terminate MCS when eligibility for ABD cash assistance, HEN Referral, or SFA for Survivors of Certain Crimes ends.

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Application for Medicare

Revised date
Purpose statement

To clarify the Medicaid eligibility requirement to apply for Medicare.

WAC 182-503-0505 Washington apple health -- General eligibility requirements.

WAC 182-503-0505 Washington apple health -- General eligibility requirements.

Effective April 27, 2019.

  1. When you apply for Washington apple health programs established under chapter 74.09 RCW, you must meet the eligibility criteria in chapters 182-500 through 182-527 WAC.
  2. When you apply for apple health, we first consider you for federally funded or federally matched programs. We consider you for state-funded programs after we have determined that you are ineligible for federally funded and federally matched programs.
  3. Unless otherwise specified in a program specific WAC, the eligibility criteria for each program are as follows:
    1. Age (WAC 182-503-0050);
    2. Residence in Washington state (WAC 182-503-0520 and 182-503-0525);
    3. Citizenship or immigration status in the United States (WAC 182-503-0535);
    4. Possession of a valid Social Security account number (WAC 182-503-0515);
    5. Assignment of medical support rights to the state of Washington (WAC 182-503-0540);
    6. Application for medicare and enrollment into medicare's prescription drug program if:
      1. You are likely entitled to medicare; and
      2. We have authority to pay medicare cost sharing as described in chapter 182-517 WAC.
    7. If your eligibility is not based on modified adjusted gross income (MAGI) methodology, your countable resources must be within specific program limits (chapters 182-512, 182-513, 182-515, 182-517, and 182-519 WAC); and
    8. Countable income within program limits:
      1. For MAGI-based programs, see WAC 182-505-0100;
      2. For the refugee program, see WAC 182-507-0130;
      3. For the medical care services program, see WAC 182-508-0005;
      4. For the health care for workers with disabilities (HWD) program, see WAC 182-511-1000;
      5. For the SSI-related program, see WAC 182-512-0010;
      6. For long-term care programs, see chapters 182-513 and 182-515 WAC;
      7. For medicare savings programs, see WAC 182-517-0100; and
      8. For the medically needy program, see WAC 182-519-0050.
  4. In addition to the general eligibility requirements in subsection (3) of this section, each program has specific eligibility requirements as described in applicable WAC.
  5. If you are in a public institution, including a correctional facility, you are not eligible for full scope apple health coverage, except in the following situations:
    1. If you are age twenty-one or younger or age sixty-five or older and are a patient in an institution for mental disease (see WAC 182-513-1317(5)); or
    2. You receive inpatient hospital services outside of the public institution or correctional facility.
  6. We limit coverage for people who become residents in a public institution, under subsection (5) of this section, until they are released.
  7. If you are terminated from SSI or lose eligibility for categorically needy (CN) or alternative benefits plan (ABP) coverage, you receive coverage under the apple health program with the highest scope of care for which you may be eligible while we determine your eligibility for other health care programs. See WAC 182-504-0125.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

Application for Medicare

Application for and enrollment into Medicare is a condition of eligibility for individuals who apply for Apple Health coverage, as long as the agency is able to pick up the cost of the premiums on the individual's behalf. Every month Apple Health eligible individuals age 65 and older who are not already receiving Medicare are asked to provide proof of application for Medicare through an automated BarCode process.

End Stage Renal Disease

The Medicare Buy-in Unit also sends letters requesting proof of application for Medicare under the End Stage Renal Disease Program (ESRD) to selected Medicaid kidney dialysis individuals who receive three consecutive months of treatment. The same process outlined above is used. The individual's letter is slightly different but still requires the individual to provide proof of application. The individual's kidney dialysis provider, (for example Northwest Kidney Dialysis Center), is also notified that they need to assist their individual with the Medicare/ESRD application process.

Individuals who fail to provide proof of application for Medicare to the Medicare Buy-in Unit under the authority of WAC 182-504-0505 and 0540 can be terminated from Apple Health assistance, including individuals who receive SSI or long-term care services. Individuals closed for noncooperation with application to Medicare will show in ACES and ProviderOne as closed for reason code 266, noncooperation with TPL.

Note: The Medicare Buy-in Unit is careful to give nearly 90 days in the two-letter process before they send an action request in BarCode to DSHS to propose termination of Apple Health coverage.

Worker Responsibilities

Every month Apple Health eligible individuals age 65 and older not already receiving Medicare are asked to provide proof of application for Medicare. The Medicare Buy-in unit in Olympia (call 1-800-562-3022) manages this workload. The following process is followed:

  1. Individuals are mailed a letter generated by barcode around the 20th of the month asking for proof of application for Medicare.
  2. The letter is provided in the individual's primary language and in English to the individual and to the individual's authorized representative. Only the English version is stored in DMS.
  3. All letters have a business reply postage paid return envelope addressed to the Medicare Buy-in Unit for returning the proof of Medicare application. Verification can be returned to any DSHS office or mailed to the DSHS Imaging Center. 
  4. Thirty days or more after the first letter is sent, the Medicare Buy-in Unit works the ticklers to review for proof of application for Medicare.
  5. If no proof is received, a second letter is sent to the individual requesting proof of application for Medicare and again ticklers are set for the Medicare Buy-in Unit to review the case for proof.
  6. If no proof is received from the second letter, the Medicare Buy-in Unit generates an action request to the worker of record asking that the individual be sent a termination of Medicaid notice under WAC 182-503-0505 General Eligibility and WAC 182-503-0540 Non Cooperation with Third Party Liability.
  7. Proof Received After Termination – If the former recipient provides verification of application for Medicare their Medicaid case can be reactivated. If the verification comes in during the period of the original certification period the case should be opened with no further contact with the individual. If verification is received after the original certification period ends than a new application is necessary.

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Eligibility review

Revised date
Purpose statement

To explain how often the agency reviews individuals' eligibility based on the health care coverage they receive and their circumstances.

WAC 182-504-0035 Washington apple health -- Renewals.

WAC 182-504-0035 Washington apple health -- Renewals.

Effective December 8, 2023.

  1. For all Washington apple health (WAH) programs, the following applies:
    1. You are required to complete a renewal of eligibility at least every 12 months with the following exceptions:
      1. If you are eligible for WAH medically needy with spenddown, then you must complete a new application at the end of each three- or six-month base period;
      2. If you are eligible for WAH alien emergency medical, then you are certified for a specific period of time to cover emergency inpatient hospitalization costs only (see WAC 182-507-0115(8));
      3. If you are eligible for WAH refugee coverage, you must complete a renewal of eligibility after 12 months; or
      4. If you are a child on apple health for kids without premiums, your first renewal is due the month of your sixth birthday.
    2. You may complete renewals online, by phone, or by paper application that you mail or fax to us (the agency or its designee).
    3. If your WAH is renewed, we decide the certification period according to WAC 182-504-0015.
    4. We review all eligibility factors subject to change during the renewal process.
    5. We redetermine eligibility as described in WAC 182-504-0125 and send you written notice as described in WAC 182-518-0005 before WAH is terminated.
    6. If you need help meeting the requirements of this section, we provide equal access services as described in WAC 182-503-0120.
  2. For programs based on modified adjusted gross income (MAGI) as described in WAC 182-503-0510:
    1. Sixty days prior to the end of the certification period:
      1. When information from electronic sources shows income is reasonably compatible (as defined in WAC 182-500-0095), we administratively renew your coverage (as defined in WAC 182-500-0010) for a new certification period and send you a notice of renewal with the information used. You are required to inform us if any of the information we used is wrong.
      2. If we are unable to complete an administrative renewal (as defined in WAC 182-500-0010), you must give us a signed renewal in order for us to decide if you will continue to get WAH coverage beyond the current certification period.
      3. We follow the requirements described in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.
    2. If your WAH coverage is terminated because you did not renew, you have 90 days from the termination date to give us a completed renewal. If we decide you are still eligible to get WAH coverage, we will restore your WAH without a gap in coverage.
  3. For non-MAGI based programs (as described in WAC 182-503-0510):
    1. Forty-five days prior to the end of the certification period, we send notice with a renewal form. You must renew before the end of the certification period by either calling the department of social and health services at the number listed on the form to renew by telephone, renew online at www.washingtonconnection.org, or mailing or delivering to the department of social and health services a signed renewal form with the information required by WAC 182-503-0005.
    2. We follow the requirements in WAC 182-518-0015 to request any additional information needed to complete the renewal process or to terminate coverage for failure to renew.
    3. To complete your renewal, you must give us all the other information requested on the application that is needed to determine your eligibility.
    4. If you are terminated for failure to renew, you have 30 days from the termination date to submit a completed renewal. If still eligible, we will restore your WAH without a gap in coverage.
  4. If we determine that you are not eligible for renewal of your WAH coverage, we:
    1. Consider your eligibility for all other WAH programs before ending your WAH coverage; and
    2. Coordinate with the health benefit exchange any request for information that is necessary to determine your eligibility for:
      1. Other WAH programs; and
      2. With respect to qualified health plans, health insurance premium tax credits (as defined in WAC 182-500-0045) and cost-sharing reductions (as defined in WAC 182-500-0020).
  5. We reconsider our decision that you are not eligible for WAH coverage without a new application from you when:
    1. We receive the information that we need to decide if you are eligible within 30 days of the date on the termination notice; or
    2. You request a hearing within 90 days of the date on the renewal denial letter and an administrative law judge (ALJ) or HCA review judge decides our decision was wrong (per chapter 182-526 WAC).
  6. If you disagree with our decision, you can ask for a hearing. If we decided that you are not eligible for renewal because we do not have enough information, the ALJ will consider the information we already have and anymore information you give us. The ALJ does not consider the previous absence of information or failure to respond in determining if you are eligible.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

Eligibility Review Periods

The table below shows when an individual's eligibility is up for review (typically the end of the certification period) for each Apple Health program.

Program Default review period
Apple Health Pregnancy Coverage (N03/N23) 12 months After Pregnancy Coverage (APC)
L99 and MN with Spenddown 3 or 6 months (chosen by applicant)
All other Apple Health programs (other than AEM) 12 months

Worker Responsibilities

Review of Current Circumstances

  1. As part of the eligibility review process for a paper review form, ensure that the person answered all questions clearly and completely. If doing a review in-person or over the telephone, ensure that all eligibility factors are reviewed.
  2. If applicable, review the record for the Equal Access (EA) plan (see EA).
  3. Review the record to see if earlier actions or changes may have an impact on eligibility.
  4. Review for eligibility factors, especially:
    1. Income for all Apple Health programs; and
    2. Resources for Classic Apple Health programs
      1. Review resources the household claims to see if there are any changes to resources we earlier excluded or decided were not available.
      2. Review funds in joint checking accounts that we excluded earlier.
      3. Review the plan to exclude business property of a self-employed person to decide if the property leads to full or partial self support.
      4. Review the value of liquid and nonliquid resources. Look for an increase in the value of real estate, cash value of life insurance, and securities that can be sold such as stocks, bonds, and certificates of deposit.
  5. Review and get proof of eligibility factors that have changed.
  6. Review and document previous proof to ensure that:
    1. Previously verified factors are clear and complete in the case file; and
    2. We are not asking the individual to give us duplicate or unneeded proof.
  7. Document proof you received.
  8. If any changes were made, send the appropriate letter.

Incomplete and Late Reviews

If an administrative review for a renewal cannot be completed and no review has been completed over the phone or in-person, then the household is ineligible for coverage. No review form is needed if the review is completed on or before the eligibility review end date or within the first 30 days after termination for Classic cases or 90 days for MAGI.

Note: If a household does not return a review form or returns it late, check the household record for an Equal Access Plan.

If you initiate a review for CN coverage, ACES keeps Apple Health open even if the individual does not return the required proof. When pending a review, set an alert to check the case and determine if the individual returned the required proof.

  1. If someone does not provide the proof you asked for, close the medical AU with advance and adequate notice (see WAC 182-518-0025).
  2. If you receive information to establish eligibility:
    1. For Classic Apple Health, within 30 days after the month the review was due, reopen coverage.
    2. For MAGI Apple Health, within 90 days after the month the review was due, Washington Healthplanfinder reopens coverage back to the first of the month following termination of coverage.

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Treatment of Income chart

Revised date
Income type SSI-Related Medical Medically Needy for Pregnant Women and Children -- Follows TANF rules
Adoption support Excluded Excluded
Adult family home See WAC 182-512-0840 See WAC 388-450-0080
Advance on wages (draws) Earned Earned
Agent Orange Act of 1991 Excluded Excluded
Agent Orange disability payments, PL 101-201 Excluded Excluded
Alaska Permanent Fund distributions Unearned Unearned
Alimony or spousal maintenance Unearned Excluded - When an individual receives TANF/SFA and payment is included with child support order
Unearned - All other payments
AmeriCorps income Excluded Excluded
AmeriCorps VISTA or Vista income

(NOTE: This is not the same as AmeriCorps only - See above)

 Excluded Excluded
Annuity Unearned Unearned
Assistance from other agencies and organizations See WAC 182-512-0860 See WAC 388-450-0055
Austrian General Social Insurance Act payments under section 500 through 506 Unearned - Interest received on these payments Excluded
Back child support See Child Support in this table. See Child Support in this table.
Blood or plasma sales See WAC 182-512-0840 See WAC 388-450-0080
Bona fide loans Excluded Excluded
Bonus

Earned - Incentive bonus based on employee performance - 

Unearned - All other bonus

 Earned - When received as an employee

Unearned - When received on an ongoing basis after employment has terminated

See Lump Sum Payments - When received as one-time-payment after employment has terminated
Bureau of Indian Affairs General Assistance  Unearned Unearned
Burial fund increase Excluded Excluded - See Resources
Cash benefits reduced as a result of sanction or noncooperation N/A N/A
Cash payments from government, public, or private medical or social service agency Excluded See specific income type
Cash prizes, awards. lottery winnings Unearned See Lump Sum Payments
CEAP N/A N/A
CEAP - For TANF/SFA households terminated while in WorkFirst sanction within the last six months.
(NCS termination) 		 Unearned - TANF/SFA Unearned - TANF/SFA
Census Bureau wages:
  • Earnings from temporary work for the 2020 census
 Excluded

Earned Income

 Excluded

Earned Income
Charitable cash donations See WAC 182-512-0860 See WAC 388-450-0055
Child support received by the individual, current and ongoing payments

Unearned - income of the child

Excluded - TANF/SFA recipients

Unearned - Non-TANF/SFA - income of the child

Unearned - TANF/SFA applicant that received payment before benefits are opened - income of the child
Child support received by the individual, payments in arrears Unearned - income of the child Unearned - income of the parent 
Child support pass-through payments See WAC  182-512-0820 Excluded - TANF/SFA recipients
Child support (legally obligated) paid by the individual Disregarded - See WAC 182-512-0920 Disregarded - See Income - Allocation and Deeming
Civil liberties payments, PL 100-383. Restitution payments made under the Wartime Relocation of Civilian's Act Excluded Excluded
COLA increases in Title II SSA beneficial Excluded Unearned
Combat Veteran Program Funds Excluded Excluded
Combat pay - Special pay while serving in a combat zone. Excluded
Increased amount paid to assistance unit while service member is deployed to a combat zone.		 Excluded
Increased amount paid to assistance unit while service member is deployed to a combat zone.
Court ordered payments other than Child Support  Lump-Sum Payment
Amount paid as a one-time payment

Unearned
Amount paid in multiple (more than one) payments

 Lump-Sum Payment
Amount paid as a one-time payment

Unearned
Amount paid in multiple (more than one) payments
Crime Victims Compensation Funds funded under PL 103-322 (Whether ran by state or federal program.) Excluded Excluded
Crime Victims Compensation (State-funded benefit through L&I) Unearned - Amount paid to replace lost wages

Reimbursement - See Reimbursements in this table

 Unearned - Amount paid to replace lost wages

Reimbursement - See Reimbursements in this table
Deemed income from an alien's sponsor Unearned - See WAC 182-512-0795 Unearned - See WAC 388-450-0155, WAC 388-450-0156 and WAC 388-450-0160
Disaster assistance to farmers when authorized under the Secretary of Agriculture under PL 100-387 Excluded Excluded
Disaster relief & emergency assistance under PL 93-288, amended by PL 100-707  Excluded Excluded
Disaster Unemployment Assistance (DUA) Excluded Excluded
Diversion Cash Assistance (DCA) N/A N/A
Dividends or Interest  Unearned Unearned
Drug (illicit) sales Earned - Minus self-employment expenses Earned - Minus self-employment expenses
Earned income of a child See WAC 182-512-0820 See WAC 388-450-0070
Earned income incentives and disregards for cash assistance See WAC 182-512-0840 See WAC 388-450-0170 TANF/SFA earned income incentive and deduction
Earned income in-kind (working in exchange for rent, vehicle, TV) Earned Earned
Earned income of an ineligible or nonapplying person under 21 years of age, when this person is a student Excluded Excluded
Earned Income Tax Credit (EITC) Excluded - See Resources Excluded - See Resources
Economic Opportunity Act Earned Earned
Economic Security for All (EcSA) Excluded Excluded
Educational assistance - Opportunity grants Excluded Excluded
Educational benefits See WAC 182-512-0760 See WAC 388-450-0035
Egg or sperm donation See WAC 182-512-0840 See WAC 388-450-0080
Emergency Additional Requirement Payments authorized to TANF/SFA and RCA individuals N/A N/A
Employment or training programs income See WAC 182-512-0780 See WAC 388-450-0045
Energy Assistance Payments (LIHEAP) Excluded Excluded
Fellowships with work requirements Earned Earned
First $20 per month of an individual's earned or unearned income Excluded N/A
First $65 per month of an individual's earned income, plus one-half of remainder Excluded N/A
Flexible benefits Earned - When an individual has option to cash out.
(Count the amount the individual can receive as cash whether or not they choose to receive the benefit in cash.) See Income - Ownership and Availability		 Earned - When an individual has option to cash out.
(Count the amount the individual can receive as cash whether or not they choose to receive the benefit in cash.) See Income - Ownership and Availability
Food benefits under the Food and Nutrition Act of 2008 (includes tribal commodities) Excluded Excluded
Food Service Program for Children under the National School Lunch Act of 1966, PL 92-433 and 93-150 Excluded Excluded
Foster Care maintenance payments Excluded Excluded
Foster care retainer fees Earned Earned
Foster Grandparents Program under Title II of P.L. 93-113 Excluded Excluded
Funds for shared household costs Excluded Excluded
Gambling winnings Unearned Unearned
Gate money from adult corrections Unearned Unearned
Gift cards Excluded Excluded
Gifts See WAC 182-512-0800 See WAC 388-450-0065
Gifts to children with life-threatening conditions, PL 105-306 Excluded Excluded
Health Profession Opportunity Grant (HPOG) funds Excluded Excluded
Homeless Workers Stipend Program Excluded Excluded
HUD Community Development block grant funds Excluded Excluded
HUD rental and/or utility subsidies under Section 8 of the housing act Excluded Excluded
Income an individual's ineligible or nonapplying spouse receives from a government agency (such as CHORE services) Excluded See specific income type
Income specifically excluded from being counted as income under federal law Excluded Excluded
Income tax refund Excluded Excluded
Income used for the cost of producing self-employment income See WAC 182-512-0840 See WAC 388-450-0080
Income which causes an individual to lose SSI eligibility due solely to the reduction in the state supplement (SSP) Excluded See specific income type
Individual & family grant program payments N/A N/A
Infrequent or irregular income

Excluded - Up to $30 earned per quarter
Excluded - Up to $60 unearned per quarter

 Excluded - Up to $30 per quarter
Insurance settlements Excluded - See Lump Sum Payments Excluded - See Lump Sum Payments
Interest received on repayments made to the individual Unearned Unearned
Investment income Unearned Unearned
Job Corps income (under WIA) See WAC 182-512-0780 See WAC 388-450-0045
Joint bank accounts Unearned - If the individual withdraws more than their share of the money Unearned - If the individual withdraws more than their share of the money
JTPA income See WAC 182-512-0780 See WAC 388-450-0045
Jury duty income Unearned Excluded
Life estate income Unearned Unearned
Lived Experience (or Community) Compensation Excluded Excluded
Loan repayments made to individuals (principal only) Excluded Excluded
Low-Income Home Energy Assistance Act (LIHEAA) under P.L. 99-425 Excluded Excluded
Lump sum payments See WAC 182-512-0700 See WAC 388-455-0015
Maternity leave pay (individual still employed) Earned Earned
Meals Earned - See WAC 182-512-0800

Disregarded - When provided by employer at no charge
Earned - When deducted from paycheck by employer
Military pay Earned Earned
Money excluded by the Social Security Administration (SSA) in a Plan for Achieving Self-Support (PASS) Under PL 102-237 Excluded Excluded
Money received for an absent or non household member Excluded
Unearned - Any portion retained by the AU		 Excluded
Unearned - Any portion retained by the AU
Money withheld for payment of legal obligation Unearned Excluded
Montgomery G I Bill See WAC 182-512-0760 See WAC 388-450-0035
Monthly allowances paid to children of Vietnam Veterans who are born with birth defects, PL 106-419, PL 104-204 Excluded Excluded
Native American benefits & payments

See WAC 182-512-0770 and WAC 182-512-0860  Also see the tribal income desk aid

 See WAC 182-512-0770  Also see the tribal income desk aid

Nutrition Assistance Program (NAP) benefits from

Puerto Rico, American Samoa, or Northern Mariana Islands

 Excluded Excluded
Ongoing Additional Requirements Excluded Excluded
On-the-job training wages See WAC 182-512-0780 See WAC 388-450-0045
Opportunity Grants Excluded Excluded
Panhandling Unearned Unearned
PASS income is money excluded by the Social Security Administration (SSA) in a Plan for Achieving Self-Support (PASS) Excluded Excluded
Payments under the Child Nutrition Act of 1966 P.L. 89-642 Excluded Excluded
Payments form the Dutch Government, under the Netherlands ' Act on Benefits for Victims of Persecution (WUV)

Excluded

Unearned - Interest earned on these payments

 Excluded
Payments under the Federal Republic of Germany 's Law for Compensation of National Socialist Persecution or German Restitution Act

Excluded

Unearned - Interest earned on these payments

 Excluded
Payments Under the Filipino Veterans Equity Compensation Fund
(Division A, Title X, Section 1002 of American Recovery and Reinvestment Act of 2009 ARRA)		 Excluded Excluded
Payments to persons age 55 and older under the Senior Community Services Employment Program (SCSEP) under Title V of the Older Americans Act of 1987.

Earned income if paid as a wage or salary
Excluded if reimbursement of expenses or payment for services such as education, clothing or transportation.

 Excluded
Pensions Unearned Unearned
Prostitution Earned - Minus self-employment expenses Earned - Minus self-employment expenses
Public assistance (including tribal TANF) Unearned Unearned
Radiation exposure compensation, under PL 101-426 and PL 106-398 Energy Employees Occupational Illness Compensation Act (EEOICA) 2000. Excluded Excluded
Railroad Retirement Benefits (RRB) Unearned Unearned
Real estate / mortgage sales and contracts Contract - See Resources

Unearned - Payments from contract

 Contract - See Resources

Unearned - Payments from contract
Reemploy Washington Workers (RWW) cash incentive N/A N/A
Refund by any public agency of taxes paid on real property or on food Excluded N/A
Reimbursements Excluded Unearned - Amounts in Excess of expenses Earned - Amounts in Excess of expenses when paid by employer Excluded Unearned - Amounts in Excess of expenses Earned - Amounts in Excess of expenses when paid by employer
Rental or lease property income See WAC 182-512-0840 See WAC 388-450-0080
Representative payee fees Excluded N/A
Residuals Earned Earned
Retirement Unearned Unearned
Retired Senior Volunteer Program (RSVP) under Title II of P.L. 93-113 Excluded Excluded
Retroactive benefits (SSA, SSI, PA, UC, and VA) Excluded Excluded - See Lump Sum Payments
Retroactive WCCC payments Excluded Excluded
Reverse mortgage Excluded Excluded
Ricky Ray Hemophilia Relief Fund Act of 1998 Excluded Excluded
Room and board income See WAC 182-512-0750 See WAC 388-450-0080
Royalties Earned Unearned
Savings bond interest Unearned Unearned
Securities income Unearned Unearned
Security deposit refunds Disregarded See WAC 182-513-1345 Excluded
 
Self-employment income See WAC 182-512-0840 See WAC 388-450-0080 and WAC 388-450-0085
Self-employment income normally allowed as an income deductions by the IRS Excluded Excluded
Senior Companion Program under Title II of P.L. 93-113 Excluded Excluded
Settlements See Lump Sum Payments See Lump Sum Payments
Shared leave Earned Earned
Sick leave pay (individual still employed) Earned Earned
SSDI Unearned Unearned
SSI Excluded Excluded
SSI-related individual's income to meet the needs of ineligible minor child Excluded See specific income type
SSI Income or State Supplement Payment (SSP) Excluded Excluded
Strike benefits Unearned Unearned
Strike benefits for picket duty Earned Earned
Student loans See WAC 182-512-0760 See WAC 388-450-0035
Summer youth employment or training programs Earned Earned
Support payment on behalf of a household member (paid directly to a third party) Excluded See Vendor Payment in Worker Responsibilities
Surrogate mother services Earned - Minus self-employment expenses Earned - Minus self-employment expenses
Susan Walker v. Bayer Corporation, settlement funds Excluded
Unearned - Interest earned on these payments		 N/A
Tax rebates or special payments excluded under other laws Excluded Excluded
Time loss compensation Unearned - See Chapter 182-512 WAC Unearned See WAC 388-450-0010
Title I, II, III of the Domestic Volunteer Act of 1973, PL 93-113 - Including VISTA See WAC 182-512-0780 See WAC 388-450-0045
Title I of the Elementary and Secondary Education Act Earned Earned
Title I of the National & Community Service Act of 1993 (NCSA) (includes AmeriCorps Programs & Higher Education Service - Learning Program) See WAC 182-512-0780 See WAC 388-450-0045
Training allowances for GA-U individuals See WAC 182-512-0780 See WAC 388-450-0045
Training allowances from vocational and rehabilitation programs See WAC 182-512-0780 See WAC 388-450-0045
Travel advances Earned - If a contract exists
Earned - Minus expenses if no contract exists		 Earned - If a contract exists
Earned - Minus expenses if no contract exists
Unearned income in-kind (supplied) Unearned Excluded
Unemployment Compensation (UC) - before deductions Unearned
Note: Federal UC stimulus payments made under the American Recovery & Reinvestment Act of 2009 (ARRA) and the Worker, Homeownership, and Business Assistance Act of 2009 are disregarded when computing benefits for all programs.		 Unearned
Note: Federal UC stimulus payments made under the American Recovery & Reinvestment Act of 2009 (ARRA) and the Worker, Homeownership, and Business Assistance Act of 2009 are disregarded when computing benefits for all programs.
Uniform Relocation Assistance & Real Property Acquisition Policies Act of 1970, PL 94-646, section 218 Excluded Excluded
Vacation pay Earned Earned
Vendor payments Excluded Excluded
Veteran Administration benefits (service connected compensation or improved pension)

Unearned

See Clarifying Information below

See WAC 182-512-0840

 Unearned
Veteran's benefits designated for the veteran's dependent

Excluded to the individual
Countable to the dependent/spouse

 Unearned
Veteran's benefits designated as aid and attendance or housebound allowance Excluded Unearned
Veteran's benefits designated as Unusual Medical Expenses (UME) Excluded

Unearned
Victims of Nazi Persecution payments under P.L.103-286 Excluded Excluded
VOLAG - One time payments Excluded Excluded
VOLAG - Ongoing payments including Matching Grant Program Unearned Counted as assistance from another agency or organization under WAC 182-512-0860 See WAC 388-450-0055
Wages, salaries, commissions, profits Earned Earned
Witness pay Excluded  Excluded 
Women, Infants & Children benefits (WIC) Excluded Excluded
Work experience wages from Employment Security Department See WAC 182-512-0780 See WAC 388-450-0045
WorkFirst Supportive Service payments See WAC 182-512-0780 See WAC 388-450-0045
WorkFirst Career Services benefits Unearned

See Chapter 388-310 WAC
WorkForce Training Funds - Training Completion (TECA) See WAC 182-512-0860 See WAC 388-450-0055
Working Family Tax Credit Excluded Excluded
Work related expenses Excluded - If impairment related N/A
Work study See WAC 182-512-0760 See WAC 388-450-0035

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Community First Choice

Revised date
Purpose statement

To explain the Community First Choice (CFC) program that provides long-term services and supports (LTSS). CFC is for people living outside of a medical institution, who are eligible for categorically needy (CN) or alternate benefit plan (ABP) scope of care through Medicaid, and who meet nursing facility level of care (NFLOC) or the criteria to reside in an Intermediate Care Facility for the Intellectually Disabled (ICF/ID). CFC starts 7/1/2015

Functional eligibility is based on a CARE assessment under Chapter 388-106 WAC and 388-828 WAC and can be authorized by Home and Community Services (HCS) or Developmental Disabilities Administration (DDA).

WAC 182-513-1210 Community First Choice (CFC) – Overview

WAC 182-513-1210  Community First Choice (CFC) – Overview

Emergency effective February 20, 2017

  1. ​Community first choice (CFC) is a Washington apple health state plan benefit authorized under Section 1915(k) of the Social Security Act.
  2. CFC enables the agency and its contracted entities to deliver person-centered home and community based long-term services and supports (LTSS) to medicaid-eligible people who meet the institutional level of care under WAC 388-106-0355. See:
    1. WAC 388-106-0270 through 388-106-0295 for services included within the CFC benefit package.
    2. WAC 182-513-1215 for financial eligibility for CFC services.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-513-1215 Community First Choice (CFC) – Eligibility

WAC 182-513-1215 Community First Choice (CFC) – Eligibility

Effective February 25, 2023

  1. A client who is determined functionally eligible for community first choice (CFC) services under WAC 388-106-0270 through 388-106-0295 is financially eligible to receive CFC services if the client is:
    1. Eligible for a noninstitutional Washington apple health (medicaid) program which provides categorically needy (CN) or alternative benefits plan (ABP) scope of care;
    2. Through September 30, 2027, a spousal impoverishment protections institutional (SIPI) spouse under WAC 182-513-1220; or
    3. Determined eligible for a home and community based (HCB) waiver program under chapter 182-515 WAC.
  2. A client whose only coverage is through one of the following programs is not eligible for CFC:
    1. Medically needy program under WAC 182-519-0100;
    2. Premium-based children's program under WAC 182-505-0215;
    3. Medicare savings programs under WAC 182-517-0300;
    4. Family planning program under WAC 182-505-0115;
    5. Family planning only under chapter 182-532 WAC
    6. Medical care services program under WAC 182-508-0005;
    7. Pregnant minor program under WAC 182-505-0117;
    8. Alien emergency medical program under WAC 182-507-0110 through 182-507-0120;
    9. State-funded long-term care (LTC) for noncitizens program under WAC 182-507-0125; or
    10. Kidney disease program under chapter 182-540 WAC.
  3. Transfer of asset penalties under WAC 182-513-1363 do not apply to CFC applicants, unless the client is applying for long-term services and supports (LTSS) that are available only through one of the HCB waivers under chapter 182-515 WAC.
  4. Home equity limits under WAC 182-513-1350 do apply.
  5. Post-eligibility treatment of income rules do not apply if the client is eligible under subsection (1)(a) or (b) of this section.
  6. Clients eligible under subsection (1) (a) or (b) of this section, who reside in an alternate living facility (ALF):
    1. Keep a personal needs allowance (PNA) under WAC 182-513-1105; and
    2. Pay up to the room and board standard under WAC 182-513-1105 except when CN eligibility is based on the rules under WAC 182-513-1205.
  7. A client who receives CFC services under the health care for workers with disabilities (HWD) program under chapter 182-511 WAC must pay the HWD premium in addition to room and board under WAC 182-513-1105, if residing in an ALF.
  8. Post-eligibility treatment of income rules do apply if a client is eligible under subsection (1)(c) of this section.
  9. A client may have to pay third-party resources as defined under WAC 182-513-1100 in addition to the room and board and participation.
  10. PNA, MNIL, and room and board standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-513-1220 Community First Choice (CFC) - Spousal impoverishment protections for noninstitutional Washington Apple Health clients

WAC 182-513-1220 Community First Choice (CFC) - Spousal impoverishment protections for noninstitutional Washington Apple Health clients.

Effective February 25, 2023

  1. This section is effective through September 30, 2027.
  2. The agency or its designee determines eligibility for community first choice (CFC) using spousal impoverishment protections under this section, when an applicant:
    1. Is married to, or marries, a person not in a medical institution;
    2. Meets institutional level of care and eligibility for CFC services under WAC 388-106-0270 through 388-106-0295;
    3. Is ineligible for a noninstitutional categorically needy (CN) SSI-related program:
      1. Due to spousal deeming rules under WAC 182-512-0920, or due to exceeding the resource limit in WAC 182-512-0010, or both; or
      2. In an ALF due to combined spousal resources exceeding the resource limit in WAC 182-512-0010; and
    4. Meets the aged, blindness, or disability criteria under WAC 182-512-0050.
  3. The agency or its designee determines countable income using the SSI-related income rules under chapter 182-512 WAC but uses only the applicant's or recipient's separate income and not the income of the applicant's or recipient's spouse.
  4. The agency or its designee determines countable resources using the SSI-related resource rules under chapter 182-512 WAC, except pension funds owned by the spousal impoverishment protections community (SIPC) spouse are not excluded as described under WAC 182-512-0550:
    1. For the applicant or recipient, the resource standard is $2000.
    2. Before determining countable resources used to establish eligibility for the applicant, the agency allocates the state spousal resource standard to the SIPC spouse.
    3. The resources of the SIPC spouse are unavailable to the spousal impoverishment protections institutionalized (SIPI) spouse the month after eligibility for CFC services is established.
  5. The SIPI spouse has until the end of the month of the first regularly scheduled eligibility review to transfer countable resources in excess of $2000 to the SIPC spouse.
  6. A redetermination of the couple's resources under subsection (4) of this section is required if:
    1. The SIPI spouse has a break in CFC services of at least 30 consecutive days;
    2. The SIPI spouse's countable resources exceed the standard under subsection (4)(a) of this section; or
    3. The SIPI spouse does not transfer the amount under subsection (5) of this section to the SIPC spouse by the end of the month of the first regularly scheduled eligibility review.
  7. If the applicant lives at home and the applicant's separate countable income is at or below the SSI categorically needy income level (CNIL) and the applicant is resource eligible, the applicant is a SIPI spouse and is financially eligible for noninstitutional CN coverage and CFC services.
  8. If the applicant lives in an ALF, has separate countable income at or below the standard under WAC 182-513-1205(2), and is resource eligible, the applicant is a SIPI spouse and is financially eligible for noninstitutional CN coverage and CFC services.
  9. Once a person no longer receives CFC services for 30 consecutive days, the agency redetermines eligibility without using spousal impoverishment protection, under WAC 182-504-0125.
  10. If the applicant's separate countable income is above the standards under subsections (7) and (8) of this section, the applicant is not eligible for CFC services under this section.
  11. The spousal impoverishment protections under this section expire on September 30, 2027.
  12. Standards are found at www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/program-standard-income-and-resources.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

The department authorizes CFC for a person who meets both:

  1. Institutional level of care based on the assessment by HCS or DDA case manager or HCS social worker; and
  2. Financial eligibility for a CN or ABP Medicaid program, including receiving CN through a HCB waiver. A person may receive both CFC and HCB waiver services at the same time.

Which community settings are used for CFC?

CFC can be authorized in a:

  1. Person's home; or
  2. HCS or DDA contracted alternate living facilities (ALF) contracted for CFC services.

What is the resource limit for CFC?

The resource limit is based on the CN or ABP program rules that the client is receiving:

  1. For people eligible under the MAGI-based programs through the Health Benefit Exchange there is no resource limit;
  2. For people eligible under Apple Health for Workers with Disabilities (HWD) there is no resource limit;
  3. For people eligible under SSI-related programs;
    1. The single person resource limit is $2,000
    2. The married couple resource limit is $3,000
    3. The married couple resource limit using spousal impoverishment is $2,000 for the recipient and $54,726 for the community spouse beginning July 1, 2015. See resource standards.

The resource standard is found on the Standards - LTC and LTSS page.

Do transfer penalties apply to CFC?

Transfer penalties do not apply to people who only receive CFC. Transfer penalties do apply to home and community based (HCB) waivers described in 182-515 WAC. If a person needs CFC in combination with HCB waiver services, transfer penalty rules described in WAC 182-513-1363 apply.

Does the home equity limit apply to CFC?

The home equity limit described in WAC 182-513-1350 applies to CFC because it is considered "Long-Term care" under the Social Security Act

How does the eligibility process work?

If the client is not eligible for MAGI we need to consider eligibility for a classic Medicaid program under one of the groups listed below.

Group Income Resources Notes
  CFC Eligibility Only (L52*)  
Group A 2-person CNIL (married plus deemed income)

$3,000 (married living together)

$2,000 (all other)

 Regular S02 rules
Group B 1-person CNIL State CSRA With community Spouse (CS)
Group C SIL and state rate plus $38.84 $2,000 Not income eligible in Group A, lives in a contracted ALF
Group D SIL and state rate plus $38.84 state CSRA With CS, not resource eligible in Group C
    HCB Waiver plus CFC or HCB Waiver Eligibility (L22/L32* / L42*)  
Group 1 Otherwise eligible using Group A $2,000 (single) state CSRA with (CS) HCS & DDA
Group 2 Not Group A, but < SIL $2,000 (single) state CSRA (with CS) HCS & DDA
Group 3 Not Group 2, but < Effective MNIL $2,000 (single) state CSRA (with CS) HCS Only (no hospice only)
Coverage group Description
L51 CFC SSI
L52 CFC SSI-Related

If a client is disabled and under 65 with earnings and not eligible under group A or group B, check to see if HWD is a better option than group C or D or under HCB waiver rules. A person can receive CFC under the HWD program.

Do clients pay participation on CFC services?

Clients living at home and only receiving CFC will have no participation.

If a CFC eligible person lives in an ALF:

  1. And is eligible under Group A or Group B, this person keeps their personal needs allowance (PNA) and pays up to the Room and Board standard.
  2. And is eligible under Group C or Group D, the person keeps their PNA, pays Room and Board, and pays the remainder of their income to their provider. This total amount is called "total client responsibility"

Clients receiving CFC and waiver pay participation for both CFC and waiver services depending on setting and which administration approves the services (DDA/HCS).

Which programs are not eligible for CFC?

Title XXI Children's Health Insurance Program (CHIP) because it is not a Title XIX Apple Health program.

State-funded children

Alien emergency medical (AEM)

Medical care services (MCS)

Program of all-inclusive care for the elderly (PACE)

New freedom

Roads to community living (RCL)

Medically needy (MN)

Does spousal impoverishment apply to CFC?

If otherwise eligible under group A, group C or Health Care for Workers with Disabilities (HWD), there is no need for spousal impoverishment protections. However, if not eligible under group A or group C due to spousal deeming or resources; or if not eligible under HWD due to spousal income, we can use spousal impoverishment protections.

If an SSI-related married person is found functionally eligible for CFC, and their spouse isn’t in a medical institution, the CFC eligible person can use the financial benefits of spousal impoverishment protections in eligibility. Spousal impoverishment applies to SSI-related noninstitutional Medicaid when there is a SIPC spouse. Even using spousal impoverishment, the client applying for CFC must meet the following:

  1. Countable income in the name of the CFC eligible person must be at or below the standard for group B, group D, or HWD; and
  2. Combined resources must be at or below the state resource standard, plus $2,000 (Resources do not apply to HWD).

When we apply spousal impoverishment to CFC does it work the same as spousal impoverishment for HCB waiver?

Yes. When a client is on CFC only and is married, spousal impoverishment rules, described in WAC 182-513-1220 (for CFC), apply just like WACs 182-513-1350, 182-515-1509, and 182-515-1514 (for waiver). However, since a CFC only person doesn’t participate, post eligibility protections do not apply.

Even though spousal impoverishment rules apply to the G03 program, there is no post eligibility spousal or dependent allocation, because there is no "participation" under the G03 program. Clients must still pay room and board and their remaining income towards total client responsibility.

Spousal impoverishment doesn't apply to modified adjusted gross income (MAGI) clients.

Can a client receive both CFC and waiver services? What about hospice?

Yes. Clients can receive CFC, waiver and hospice at the same time. Waiver will be the priority program, CFC and hospice will be services. The programs will all be identified on the INST screen in ACES mainframe or Institutional Care in ACES 3G.

Are full benefit dual eligible (FBDE) recipients who receive CFC-only exempt from Medicare Part D copayments in the same way as HCB waiver recipients?

No. Under the Low Income Subsidy (LIS) Program, dual eligible clients who receive CFC-only will not be LIS 3 (like HCB waiver and institutional clients), and are subject to Medicare Part D copayments.

If a client has high Medicare Part D costs, financial staff should coordinate with social services to move the client to a HCB waiver if possible.

What if someone on CFC needs a service only available under a waiver?

If a client is on CFC only, and needs a waiver service, financial staff will receive a communication from either the HCS social worker 14-443 or DDA case manager 15-345 informing of the change. The client will remain on the waiver until their next annual assessment or significant change.

Worker Responsibilities

For CFC only, if the client is active on SSI-related CN medical a program change is needed. The social worker/case manager will notify the financial worker of the start date and type of service via the 14-443 or 15-345. The financial worker will indicate CFC. This information is coded on the institutional care tab in ACES 3G or INST screen in ACES mainframe. This AU will be managed by DDA or HCS financial worker.

For clients not on Medicaid who are under age 65 and not on Medicare, a MAGI determination through the Healthplanfinder needs to be made first.

For clients who need classic Medicaid, determine eligibility under groups A, B, C, or D. Follow eligibility requirements for Medicaid.

If the client is not eligible under groups A, B, C, or D, determine eligibility under HCS Home and Community based (HCB) waivers . The financial worker will need to notify the social worker or case manager using the barcode 07-104, indicating that HCB waiver rules are needed for CN eligibility. If DDA is unable to authorize services under a waiver, send a 07-104 to HCS intake for an HCS waiver assessment.

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